Radiographic views for hand fractures - call for three-view national UK guidelines - a quality improvement study.

A three-view radiographic examination (comprising of antero-posterior, oblique and lateral views) is crucial for the accurate assessment and subsequent decision-making in hand fracture management. The superiority of a three-view examination, compared to only two views, has been demonstrated by multiple studies, citing increased diagnostic accuracy and reduced rates of misdiagnosis. As such, the American College of Radiology (ACR) now recommends a standard three-view examination for finger and hand injuries; despite this, no formal guidance exists in the United Kingdom. Out of the 235 patients referred to our tertiary hand trauma unit with a confirmed hand fracture, less than half (45%) had three-view radiographic examination performed. Less than two-thirds (57%) of metacarpal fractures had three views available at assessment in our unit, with the lateral radiograph most commonly lacking (38%). Less than a third (30%) of phalangeal fractures had all three views, with the oblique view most commonly absent (64% of cases). Reviewed radiology protocols from six local hospitals were inconsistent; all recommended three views for suspected metacarpal fractures, but only two for suspected phalangeal injuries. Despite the superiority of a three-view examination and no additional cost of a third view, over half of the patients in this study lacked a three-view radiographic series. The authors would like to call for national published guidance advocating the use of three-view radiographic series in all patients with a high hand fracture suspicion (as defined by the presence of swelling, bruising and/or deformity) to reduce variability in local radiology hand fracture protocols and increase availability of three-view radiographs in the primary, secondary and tertiary settings.

The Ganga Hospital experience - Correspondence.

Ganga Hospital is world renowned for its' expertise in plastic and orthopaedic surgery. The international trainee can learn a great deal from this unit which offers a high volume of cases with extremely high standards of operative techniques, unparalleled work ethos and overall patient care. In this Correspondence we will give an overview of the educational opportunities available, drawn from our own experiences.

Practical Techniques to Ensure Success in Digital Ring Avulsion Injuries.

A ring avulsion results from a longitudinal traction to a digit. We discuss practical microsurgical techniques essential in achieving good functional outcomes in these challenging cases, including aggressive debridement of the affected tissues and vessels, liberal use of vein grafts and arterialized venous flow through flaps when needed, and a meticulous microsurgical technique. We have found that patient selection is key in digit salvage and a good outcome is often achieved with the winning triad of optimal patient factors, surgical factors, and intensive hand therapy. We also include a case performed by our senior author to illustrate what can be achieved.

The Wire Study-a protocol for a multi-stage feasibility study evaluating K-wire fixation of hand fractures in the UK.

BACKGROUND: Hand fractures are common and sometimes require surgery to restore function. Placement of Kirschner wires (K-wires) is the most common form of surgical fixation. After placement, a key decision is whether to bury the end of a K-wire or leave it protruding from the skin (exposed). A recent systematic review found no evidence to support either approach and a national clinician and surgeon survey demonstrated further uncertainty. We aim to determine the design of a definitive randomised controlled trial assessing the cost and clinical effectiveness of buried versus exposed Kirschner wires for adults with metacarpal or phalangeal fractures. METHODS: We will employ three methodologies: a national service evaluation of current clinical practice, patient and surgeon focus groups and a consensus meeting to finalise the protocol for a randomised controlled trial. For the service evaluation, all outcomes will be summarised using descriptive statistics overall and split by group (buried versus exposed K-wires). Information collected in the patient focus groups will be analysed thematically. The surgeon consensus meeting will address each part of the design in turn and through discussion agree a final protocol. DISCUSSION: The study may be monitored, or audited in accordance with the current approved protocol, Good Clinical Practice (GCP), relevant regulations and standard operating procedures. The Chief Investigator will submit and, where necessary, obtain approval from the above parties for all substantial amendments to the original approved documents. A feasibility study report will be published by the Wire Study Steering committee. Additional members of the steering group and citable collaborators will be listed within the manuscript and their roles identified.

A Phytophototoxic Injury at a Burns Unit: The Ungraceful After-Effects of the "Common Rue" Plant.

Phytophototoxic burn injuries refer to dermal loss after contact with light-sensitizing plants and subsequent exposure to sunlight, which can at their most severe result in full-thickness burns. Phytophototoxic injuries secondary to the Herb of Grace, otherwise known as Ruta Graveolens or the "Common rue" plant, are very rare. The authors report the first case to have been referred directly and solely managed in a specialist burns unit along with a review of the literature. The authors report a case of a 50-year-old gentleman who suffered a phytophototoxic burn injury to his hand 2 days after contact with the "common rue." Unaware of the exacerbating effects of further sun exposure, this gentleman presented with skin loss and was treated conservatively with dressings. The authors would advocate that phytophototoxic injuries secondary to the "Common Rue," which result in skin loss in special anatomical areas including the hands, feet, face, or genitalia, should be referred to a specialist burns care service to ensure that they are appropriately managed. The delay in presentation makes it vital for Burns and Plastic Surgeons treating these injuries to be aware of this plant and consider it in their differential diagnosis. Due to its widespread presence, it remains paramount to provide patient education regarding the use of appropriate protective wear and avoidance of sun for 48 hours postinjury in order to prevent exacerbation of symptoms after the initial exposure.

A useful alternative surgical technique to reconstructing large defects following excision of recurrent pilonidal sinus disease in the intergluteal region: An operative approach for the transverse lumbar artery perforator flap.

The reconstruction of defects in the intergluteal region following pilonidal sinus excision is challenging due to its anatomical location, close proximity to the anus, and being a high-tension area prone to wound-healing problems. Excision and primary closure is known to carry a higher risk of recurrence and subsequent complications compared with using nearby local healthy tissue, such as a flap, to reconstruct defect. Extra due diligence should be given to patient selection and flap choice when deciding the reconstruction of a defect. The senior author, who has briefly reviewed complication rates in previous published literature, prefers the transverse lumbar artery perforator (TLAP) flap for reconstruction following pilonidal sinus excision in the intergluteal region. This paper illustrates the operative approach used by the senior author when raising a TLAP flap.

Cardiac surgery improves survival in advanced left ventricular dysfunction: multivariate analysis of a consecutive series of 4491 patients over an 18-year period.

OBJECTIVES: Risks of cardiac surgery in patients with poor [ejection fraction (EF) ≤ 30%] and very poor left ventricular (LV) function (EF ≤ 20%) may be considered high due to increased mortality. We examine our results in this cohort of patients. METHODS: Data were prospectively collected and retrospectively analysed from 4491 consecutive patients referred for cardiac surgery over 18 years (July 1993-June 2012). Univariate predictors of in-hospital postoperative mortality were analysed by the appropriate tests. Variables with P < 0.1 were entered into multivariable logistic-regression model to identify predictors of in-hospital postoperative mortality, with data presented as odds ratios; P < 0.05 was statistically significant. Data on long-term survival and cardiac-specific mortality were obtained from the UK Office for National Statistics; the date of last follow-up was 13 October 2013 for the alive patients. Univariate predictors influencing cardiac death were determined by log-rank method. Variables with P < 0.1 were entered into multivariable Cox regression model to determine independent predictors of long-term survival, with data presented as hazard ratios; P < 0.05 was statistically significant. RESULTS: Cardiac surgery was performed on 3890 consecutive patients (74.7% male, age 68.7 ± 8.1 years); 601 patients did not undergo surgery. Postoperative hospital mortality was 2.9% (n = 112/3890). Predictors of postoperative hospital mortality included age ≥ 70 years, female sex, hypertension, LVEF < 50%, neurological dysfunction, previous cardiac surgery, early time period 1993-1997, emergency procedures and triple procedures. All patients were followed until the date of last follow-up or date of death, with a median follow-up of 8.1 ± 7.6 years and a total follow-up of 33 208 years. There were 533 (13.7%) postoperative early and late deaths from cardiac causes. Predictors of long-term survival free from cardiac death included LVEF > 50%. Predictors of postoperative cardiac deaths in the long-term follow-up included older age, diabetes, neurological dysfunction, LVEF < 50%, non-coronary artery bypass surgery, early time period of surgery (1993-1997) and redo-cardiac surgery. CONCLUSIONS: Cardiac surgery provides long-term survival benefit in all subsets of LV function, including advanced LV dysfunction.

Thiamine deficiency: a cause of profound hypotension and hypothermia after plastic surgery.

A 72-year-old woman became profoundly hypotensive and hypothermic 10 hours after undergoing a panniculectomy. She remained critically ill despite aggressive intensive care, and a diagnosis was not identified despite multiple consultations, imaging, and exploratory laparatomy. No improvement was seen until a large dose of intravenous thiamine alone was administered, dramatically restoring a normotensive and normothermic state. Although few cases of thiamine deficiency have been described in the context of plastic and reconstructive surgery, this case emphasizes the importance of considering this potentially fatal condition, which often does not manifest classically in the early postoperative period.

Telemedicine and plastic surgery: a review of its applications, limitations and legal pitfalls.

BACKGROUND: Telemedicine is a rapidly expanding technology involving the exchange of medical information to assist diagnosis and treatment at a distance. Within the field of plastic surgery, where visual examination contributes heavily to patient management decision-making, telemedicine has great potential. However, privacy and medico-legal issues must be considered when using electronic communication to assist our clinical practice. METHODS: A comprehensive literature review of manuscripts published on telemedicine was performed. Articles were selected for relevance to plastic and reconstructive surgery and reviewed for applications, benefits and complications of telemedicine. In addition, the manuscripts were reviewed for conforming to current legal guidelines for the electronic transfer of patient information. RESULTS: Twenty-nine articles met the inclusion criteria (11 trauma and burns, 4 hand, 5 wound-care, 5 maxillofacial, 1 digital replantation, 2 free-flap monitoring, and 1 technical application). Twenty-eight (96%) manuscripts reported a benefit of telemedicine (commonly including increased access to expertise and costs saved through reduction of unnecessary transfers). However only five (17%) reported a statistical benefit compared to a standard treatment cohort (face-to-face interactions). Fifteen (51%) reported on adverse effects, which included misdiagnosis, time consumption, training, technical and cost issues. Only four manuscripts (14%) discussed conforming to legal guidelines within their institution. CONCLUSIONS: Telemedicine can improve access to the specialty of plastic surgery by facilitating the provision of expertise at remote sites. Its application can be used in many situations and between a variety of healthcare professionals. However, there is little critical analysis on the benefits and risks of telemedicine. In addition, its legal implications need to be carefully considered if it is to be safely integrated into our daily practice.

Modification of N-glycosylation sites allows secretion of bacterial chondroitinase ABC from mammalian cells.

Although many eukaryotic proteins have been secreted by transfected bacterial cells, little is known about how a bacterial protein is treated as it passes through the secretory pathway when expressed in a eukaryotic cell. The eukaryotic N-glycosylation system could interfere with folding and secretion of prokaryotic proteins whose sequence has not been adapted for glycosylation in structurally appropriate locations. Here we show that such interference does indeed occur for chondroitinase ABC from the bacterium Proteus vulgaris, and can be overcome by eliminating potential N-glycosylation sites. Chondroitinase ABC was heavily glycosylated when expressed in mammalian cells or in a mammalian translation system, and this process prevented secretion of functional enzyme. Directed mutagenesis of selected N-glycosylation sites allowed efficient secretion of active chondroitinase. As these proteoglycans are known to inhibit regeneration of axons in the mammalian central nervous system, the modified chondroitinase gene is a potential tool for gene therapy to promote neural regeneration, ultimately in human spinal cord injury.